Factors related to lymph node sampling at the time of surgery in children, adolescents, and young adults with unilateral non-metastatic renal cell carcinoma.

INTRODUCTION: Renal cell carcinoma (RCC) is rare in the pediatric, adolescent, and young adult (PAYA) population. PAYA patients with RCC have a high rate of lymph node (LN) involvement, regardless of primary tumor size, yet data to guide surgical LN management in this group are limited. OBJECTIVE: The objective of this study was to determine what factors are associated with LN sampling (protocol adherence) in PAYAs with RCC. METHODS: The National Cancer Database (NCDB) between 2004 and 2013 was queried for patients aged ≤30 yrs with non-metastatic, unilateral RCC managed with surgery. Logistic regression analyses were performed to evaluate factors associated with LN sampling. RESULTS: A total of 2857 patients met study criteria. Pathologically, 2510 (87.8%) patients were Nx, 278 (9.7%) N0, and 69 (2.4%) N1. Older age was associated with omission of LN sampling (odds ration [OR]: 1.065, 95% confidence interval [CI]: 1.04-1.1, P < 0.001). Higher institutional volume (OR: 0.971, 95% CI: 0.96-0.99, P < 0.001), stage 3 tumors (OR: 0.19, 95% CI: 0.11-0.33, P < 0.001), pre-operative clinical node involvement (OR: 0.32, 95% CI: 0.12-0.86, P = 0.024), tumor size >10 cm (OR: 0.27, 95% CI: 0.12-0.57, P = 0.001), and radical nephrectomy (OR: 0.245, 95% CI: 0.16-0.38, P < 0.001) were associated with patients undergoing LN sampling. DISCUSSION: Lymph node sampling is performed in <15% of PAYA patients with RCC. Given the higher rate of translocation RCC pathology in younger patients, which leads to a higher prevalence of nodal involvement (especially with small masses), and the subsequent need for aggressive surgical control of disease, LN sampling and protocol adherence are potentially underutilized in this population and may present a unique opportunity for urologists to improve the care of PAYAs. Data from administrative databases are helpful for rare diseases such as PAYA RCC, but comes with limitations such as missing data. There are several factors that could contribute to LN sampling utilization (National comprehensive cancer network (NCCN) or Children's Oncology Group institution designation, surgeon experience, annual volume, specialty, operative approach, etc.) that cannot be further examined using the NCDB. CONCLUSION: Pediatric, adolescent, and young adult patients with localized RCC are less likely to undergo surgical LN sampling if they are older, have tumors <10 cm or of less advanced stage, have no pre-operative clinical suspicion of LN involvement, are treated with partial nephrectomy, or are treated at lower volume centers. It appears that approaches from adults with RCC are being applied to PAYAs despite evidence that PAYAs with RCC experience a significant rate of LN involvement even with small tumors.

Appropriateness for testis-sparing surgery based on the testicular tumor size in a pediatric and adolescent population.

INTRODUCTION: In children, most small testicular tumors are benign, and testicular-sparing surgery (TSS) is a viable treatment option. OBJECTIVE: The objective of this study is to assess for correlation between the tumor size and final pathologic diagnoses appropriate for TSS for pediatric and adolescent patients with an intratesticular mass and negative serum tumor markers (STMs). MATERIALS AND METHODS: A retrospective review of 24 patients (aged 0-18 years) who underwent radical or partial orchiectomy between 2003 and 2015. Patients with unifocal, unilateral intratesticular tumors and negative STMs were included. Tumors with benign and non-germ cell histology were considered appropriate for TSS, and active germ cell tumor elements on final histology were categorized as inappropriate for TSS. Baseline characteristics, tumor size, and frozen section results were evaluated for association, for the entire cohort and then for a subset of pubertal and postpubertal patients (defined as ≥10 years old). RESULTS: Patients with testicular tumor pathology inappropriate for TSS were significantly older (median age 17.1 years, P = 0.03). A 2-cm size cutoff did not accurately predict pathology for the entire cohort, or for just pubertal and postpubertal patients (P = 0.132, P = 0.154, respectively). Frozen section and final pathology demonstrated good agreement (κ = 0.826, P < 0.001) as did pre-operative and final pathologic size measurement (κ = 0.703, P < 0.001). Frozen section analysis did not miss a TSS inappropriate pathology. DISCUSSION: The present data refute the finding in adults that a 2-cm cutoff accurately predicts pathology in pediatric patients with an intratesticular mass and normal STMs. These data suggest that TSS should still be offered, regardless of the tumor size alone, but frozen section appears to more accurately predict pathology than the tumor size, and its use should, thus, be emphasized. There are several limitations of this study to mention. First, this is a retrospective review of a small cohort of patients with a rare clinical scenario, which necessitated the combination of pediatric and adolescent patients. The study did not evaluate oncologic outcomes. CONCLUSIONS: In children with an intratesticular tumor and normal STMs, a tumor size cutoff of 2 cm does not appear to accurately predict the final pathology. However, the data presented support the continued use intra-operative frozen section analysis in both children and adolescents undergoing TSS.

Development of a postoperative care pathway for children with renal tumors.

PURPOSE: To identify the factors associated with a shorter postoperative stay, as an initial step to develop a care pathway for children undergoing extirpative kidney surgery. STUDY DESIGN: This study retrospectively reviewed patients managed with upfront open radical nephrectomy for renal tumors between 2005 and 2016 at a pediatric tertiary care facility. Univariate and multivariate logistic regression were performed to identify factors associated with early discharge (by postoperative day 4). RESULTS: A total of 84 patients met inclusion criteria. Median age was 28.1 months (range 1.8-193.1). Thirty-four (40.5%) patients had a nasogastric tube postoperatively. The patients were advanced to a clear liquid diet on a median postoperative day 2 (range 0-7) and regular diet on a median postoperative day 3 (range 1-8). Median time from surgery to discharge was 5 days (range 2-12), with 38 (45.2%) discharged early. Univariate and multivariate logistic regression analyses showed that earlier resumption of regular diet (OR 0.523, P = 0.028) was positively associated with early discharge. Other analyzed factors were not significant (see Table). DISCUSSION: Timely initiation of adjuvant therapy is a specific requirement of Children's Oncology Group (COG) protocols. Chemotherapy and radiation therapy are ideally initiated simultaneously, as early as possible, within 2 weeks of surgery. Thus, factors that can facilitate early discharge from the hospital can maximize protocol adherence with respect to timing of adjuvant therapy initiation and optimize patient outcome. This study shed light on several postoperative factors and how these relate to postoperative stay and recovery. Specifically, tumor size, pre-operative bowel preparation, extent of lymph node sampling, stage, operative time, estimated blood loss, surgical service, postoperative nasogastric tube use, transfusion, and chemotherapy prior to discharge were not associated with discharge timing. Early re-feeding was associated with early discharge. Thus, it seems reasonable that, when developing a postoperative care pathway for these patients, these factors be considered and specifically encourage early re-feeding. In pediatrics, data on early recovery after surgery protocols are limited, and high-quality studies are unavailable. Within pediatric urology, early recovery after surgery protocols in children undergoing major urologic reconstruction have been shown to reduce hospital stay and can decrease complication rates. It seems reasonable that a similar pathway can be applied to children undergoing radical nephrectomy for suspected malignancy. CONCLUSIONS: For children with renal tumors who underwent radical nephrectomy, early re-feeding was associated with a shorter time to discharge. Use of bowel preparation and nasogastric tube did not appear to shorten time to discharge. These data are important for developing postoperative care pathways for these patients.

Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocol is a set of peri-operative strategies to increase speed of recovery. ERAS is well established in adults but has not been well studied in children. OBJECTIVE: The purpose of the current study was to establish the safety and efficacy of an ERAS protocol in pediatric urology patients undergoing reconstructive operations. It was hypothesized that ERAS would reduce length of stay and decrease complications when compared with historical controls. STUDY DESIGN: Institutional Review Board approval was obtained to prospectively enroll patients aged <18 years if they had undergone urologic reconstruction that included a bowel anastomosis. ERAS included: no bowel preparation, administration of pre-operative oral carbohydrate liquid, avoidance of opioids, regional anesthesia, laparoscopy when feasible, no postoperative nasogastric tube, early feeding, and early removal of intravenous fluids (IVF). Recent (2009-2014) historical controls were propensity matched in a 2:1 ratio on age, sex, ventriculoperitoneal shunt status and whether the patient was undergoing bladder augmentation. Outcomes were protocol adherence, length of stay (LOS), emergency department (ED) visits, re-admission within 30 days, re-operations and adverse events occurring within 90 days of surgery. RESULTS: A total of 26 historical and 13 ERAS patients were included. Median ages were 10.4 (IQR 8.0-12.4) and 9.9 years (IQR 9.1-11), respectively (P = 0.94) (see Summary Table). There were no significant between-group differences in prior abdominal surgery (38% vs 62%), rate of augmentation (88% vs 92%) or primary diagnosis of spina bifida (both 62%). ERAS significantly improved use of pre-operative liquid load (P < 0.001), avoidance of opioids (P = 0.046), early discontinuation of IVF (P < 0.001), and early feeding (P < 0.001). Protocol adherence improved from 8/16 (IQR 4-9) historically to 12/16 (IQR 11-12) after implementation of ERAS. LOS decreased from 8 days to 5.7 days (P = 0.520). Complications of any grade per patient decreased from 2.1 to 1.3 (OR 0.71, 95% CI 0.51-0.97). There were fewer complications per patient across all grades with ERAS. No differences were seen in emergency department (ED) visits, re-admissions and re-operations. DISCUSSION: Implementation improved consistency of care delivered. Tenets of ERAS that appeared to drive improvements included maintenance of euvolemia through avoidance of excess fluids, multimodal analgesia, and early feeding. CONCLUSION: ERAS decreased length of stay and 90-day complications after pediatric reconstructive surgery without increased re-admissions, re-operations or ED visits. A multicenter study will be required to confirm the potential benefits of adopting ERAS.

Patterns of lymph node sampling and the impact of lymph node density in favorable histology Wilms tumor: An analysis of the national cancer database.

INTRODUCTION: There is controversy about the role of lymph node (LN) sampling or dissection in the management of favorable histology (FH) Wilms tumor (WT), specifically how it performed and how it may impact survival. OBJECTIVE: The objective of this study was to analyze factors affecting LN sampling patterns and the impact of LN yield and density (number of positive LNs/LNs examined) on overall survival (OS) in patients with advanced-stage favorable histology Wilms tumor (FHWT). METHODS: The National Cancer Database (NCDB) was queried for patients with FHWT during 2004-2013. Demographic, clinical and OS data were abstracted for those who underwent surgical resection. Poisson regression was performed to analyze how factors influenced LN yield. Patients with positive LNs had LN density calculated and were further analyzed. RESULTS: A total of 2340 patients met criteria, with a median age at diagnosis of 3 years (range 0-78 years). The median number of LNs examined was three (range 0-87). Lymph node yield was affected by age, race, insurance, tumor size, laterality, advanced stage, LN positivity, and institutional volume. A total of 390 (16.6%) patients had LN-positive disease. Median LN density for these LN-positive patients was 0.38 (range 0.02-1) (Summary Figure). Estimated 5-year OS was significantly improved for those with LN density ≤0.38 vs. >0.38 (94% vs. 84.6%, P = 0.012). In this population, on multivariate analysis, age and LN density were significant predictors of OS. DISCUSSION: It is difficult to compile large numbers of cases in rare diseases like WT, and fortunately a large administrative database such as the NCDB can serve as a great resource. However, administrative data come with inherent limitations such as missing data and inability to account for a variety of factors that may influence LN yield and/or OS (specimen designation, pathologist experience, surgeon experience/volume, institutional Children's Oncology Group (COG) association, etc.). In this specific disease, the American Joint Committee on Cancer staging (captured by the NCDB) is different than the COG WT staging system that is used clinically, and the NCDB does not capture oncologic outcomes beyond OS. CONCLUSIONS: In a review of the NCDB, various factors associated with LN yield and observed LN density were identified to be significantly associated with OS in patients with LN-positive FHWT. This reinforces the need for adequate LN sampling at the time of WT surgery, to maximize surgical disease control. It was proposed that LN density as a metric may allow for improved risk-stratification, and possibly allow for therapeutic reduction in a sub-set of patients with low LN density.

Transcription elongation factor SII interacts with a domain of the large subunit of human RNA polymerase II.

Genomic sequences for the large subunit of human RNA polymerase II corresponding to a part of the fifth exon were inserted into an expression vector at the carboxy-terminal end of the beta-galactosidase gene. The in-frame construct produced a 125-kilodalton fusion protein, containing approximately 10 kilodaltons of the large subunit of RNA polymerase II and 116 kilodaltons of beta-galactosidase. The purified bacterially produced fusion protein inhibited specific transcription from the adenovirus type 2 major late promoter, while beta-galactosidase had no effect. This effect of the fusion protein was during RNA elongation, not at the level of initiation, resembling the faithfully initiated but incomplete transcripts produced with purified factors in the absence of SII. Similarly, monoclonal antibody 2-7B, which reacts with the RNA polymerase II region represented in the fusion protein, inhibited specific transcription at the level of elongation in a whole-cell extract. Both monoclonal antibody 2-7B and the fusion protein, although unable to inhibit purified RNA polymerase II in a nonspecific transcription assay, selectively blocked the stimulation elicited by transcription elongation factor SII on the activity of the purified enzyme in vitro. This suggests that the fusion protein traps the SII in nonstimulatory interactions and that antibody 2-7B inhibits SII binding to RNA polymerase II. Thus, this suggests that an SII-binding contact required for specific RNA elongation resides within the fifth exon region of the largest RNA polymerase II subunit.

Accelerated response to reinoculation in experimental allergic encephalomyelitis: histopathologic study.

Experimental allergic encephalomyelitis (EAE) was induced in Lewis rats by the injection of spinal cord tissue or myelin basic protein and adjuvants (Freund's or carbonyl iron or pertussis vaccine), or by adoptive immunization. After an interval of five to 12 weeks, the recovered rats were reinoculated by a different route and usually with a different adjuvant. The onset of the second attack was determined by the histologic detection of EAE lesions at intervals during the incubation period. In each of ten experiments, the second attack of EAE occurred one or two days earlier than in naive controls injected at the same time. Residual EAE lesions left over from the first attack could not explain the findings in the reinoculated rats. The accelerated response to the second inoculation may be related to the anamnestic response of classical immunology or to residual damage to the blood-brain barrier. Resistance to a second attack was not encountered in this histopathologic study.

The hyperacute form of allergic encephalomyelitis produced in rats without the aid of pertussis vaccine.

The hyperacute form of experimental allergic encephalomyelitis (EAE), characterized by a short incubation period, severe paralysis, high mortality, and abundant polymorphonuclear leukocytes and fibrin in the lesions, was produced in rats without the use of pertussis vaccine (previously considered an essential requirement) or Freund's adjuvant. Carbonyl iron or mineral oil without mycobacteria were effective adjuvants and whole rat spinal cord was the best antigen. Hyperacute EAE was produced in this manner in some Lewis rats, most dark agouti (DA) rats and most F1 hybrids of these two strains. Clinical signs were earlier in onset and more severe in the DA strain than in the Lewis strain in all adjuvant-antigen combinations that were tested. Dark agouti rats developed clinical signs in six days, histological lesions in five days, and localized EAE lesions could be induced in four days. The data support the hypothesis that hyperacute type lesions (neutrophils and fibrin) can be caused by an exceptionally strong immune response to neural antigen, whether that response is engendered by a particular adjuvant (pertussis vaccine) or by an unusual degree of genetic susceptibility (DA rats).

Inflammatory siderosis of the nervous system in rats.

Large intravenous doses of a relatively nontoxic iron polymaltose complex were taken up by liver and spleen and did not enter the central nervous system (CNS) of normal rats. When the injections were given during development of the inflammatory lesions of experimental allergic encephalomyelitis (EAE), many iron-laden macrophages entered vessels, perivascular cuffs and neural parenchyma. Iron polymaltose injected before the EAE lesions started to develop, or during the healing phase, did not enter the lesions. This model of CNS siderosis may be useful for studies on long-term effects of iron and for neuroimaging by nuclear magnetic resonance.

Encephalitogenicity for rats of myelin basic protein without the aid of water-in-oil emulsions.

The induction of experimental allergic encephalomyelitis (EAE) with purified myelin basic protein (MBP) has, heretofore, required its incorporation in a water-in-oil emulsion or adsorption on particulate adjuvants. In the present work, the absorption of a saline solution of MBP from the peritoneal cavity into the mediastinal lymph nodes was increased by giving repeated inoculations or by pretreating rats with a peritoneal irritant. Under these conditions, the only adjuvant needed for production of EAE was aqueous pertussis vaccine which was injected separately a few hours or one day after the MBP. Pertussis vaccine was also necessary for production of EAE with intradermal injection of aqueous MBP. By injecting the aqueous MBP directly into pre-enlarged popliteal lymph nodes, it was possible to produce EAE without the pertussis vaccine. Thus, EAE can be induced in rats using MBP without the addition of Freund's adjuvant or pertussis vaccine.

Proliferation of glial cells in vivo induced in the neural lobe of the rat pituitary by lithium.

Lithium salts are widely used for treatment of psychiatric illness. Lithium also affects cell proliferation. During investigation of the effect of lithium chloride on the central nervous system (CNS) of nephrectomized rats, we noted numerous mitotic figures in the neural lobe of the pituitary. Morphologic criteria established that the mitotic cells were astrocytes, the supporting glial cells of the CNS, also known as pituicytes. Equimolar doses of chlorides of chemically related cations (sodium, potassium, rubidium) had no such effect.

Proliferation of glial cells induced by lithium in the neural lobe of the rat pituitary is enhanced by dehydration.

Rats dehydrated by 6 days of water deprivation had a low level of mitotic activity in the astrocytes ('pituicytes') of the neural lobe of the pituitary. Mitotic activity in the pituicytes was greatly increased when isotonic lithium was administered in the last 3 days of water deprivation. Rehydration on the last day of the experiment produced a further increase in mitoses. Isotonic solutions of sodium, potassium or rubidium chloride did not increase mitoses. This model of cell proliferation is of interest because the mitotic activity is related to a physiological attempt to maintain homeostasis rather than a response to injury or the development of neoplasia.

Androgen receptor: an overview.

The action of androgens in regulating development and growth is mediated by androgen receptor (AR). AR is a member of the steroid hormone receptor superfamily, a class of receptors that function through their ability to regulate the transcription of specific genes. The AR is located in various target tissues, with its levels and activity altered with the onset of various cellular events (e.g., sexual development, malignant transformation). The modulation of AR levels occurs through a number of mechanisms, including transcription, and is regulated by various factors (e.g., androgens). The ability of AR to modulate gene transcription is through its interaction with specific DNA sequences located near or within the target gene promoter. The importance of the AR in reproductive physiology has been emphasized by the finding of AR mutations, leading to a variety of disorders, including testicular feminization syndrome. In this article, we review the structure and function of AR and the role AR plays in the function of the mammalian system.

hUBC9 associates with MEKK1 and type I TNF-alpha receptor and stimulates NFkappaB activity.

hUBC9, an E2 ubiquitin conjugating enzyme, was identified by yeast two-hybrid screening and coprecipitation studies to interact with MEKK1 and the type I TNF-alpha receptor, respectively. Because both of these proteins regulate NFkappaB activity, the role of hUBC9 in modulating NFkappaB activity was investigated. Overexpression of hUBC9 in HeLa cells stimulated the activity of NFkappaB as determined by NFkappaB reporter and IL-6 secretion assays. hUBC9 also synergized with MEKK1 to activate NFkappaB reporter activity. Thus, hUBC9 modulates NFkappaB activity which, at least in part, can be attributed to its interaction with MEKK1 and the type I TNF-alpha receptor.

Increased hemagglutinins after intraperitoneal immunization in postinflammatory state.

Hemagglutinins to xenogeneic erythrocytes were increased in rats if intraperitoneal immunization was performed during the healing phase of a chemical peritonitis. Increased absorption of the antigen into lymph nodes draining the peritoneal cavity was probably responsible for the enhanced immune response.

Method for systemic anaphylactic challenge in the rat using subplantar route.

Intravenous injection of antigen is the fastest and most effective way of eliciting anaphylactic shock in previously sensitized rats. When intravenous injection is difficult or undesirable, subplantar challenge is a preferable alternative to the intraperitoneal route.

Percutaneous inoculation of lymph nodes.

Injections into rat lymph nodes are easily performed percutaneously, without the need for a skin incision, if the nodes are enlarged in advance. The requisite enlargement of the popliteal lymph node can be obtained in 2 or 3 weeks by a single injection of tin powder or other particulate material into the foot. This method may be especially useful when multiple intranodal inoculations are contemplated.

Extrinsic allergic alveolitis after Aspergillus fumigatus inhalation. Evidence of a type IV immunologic pathogenesis.

Three weeks after a massive inhalation of mold present on infected oats, a farmer's wife had extrinsic allergic alveolitis. Aspergillus fumigatus was cultured from the moldy oats and from deep bronchial washings obtained at fiberoptic bronchoscopy. Spores and hyphae characteristic of Aspergillus species were demonstrated within granulomas in the pulmonary tissue obtained by transbrochial biopsy. Serum precipitins, delayed (48 hour) cutaneous hypersensitivity and in vitro lymphocyte transformation to A. fumigatus were demonstrated. The findings in this case suggest that a type IV immunologic response and subsequent (lymphocyte-mediated) tissue inflammation may underlie the pathogenesis of this and other forms of hypersensitivity pneumonitis.

Regional suppression, therapy after onset and prevention of relapses in experimental allergic encephalomyelitis by mitoxantrone.

Mitoxantrone, a new antineoplastic anthracenedione drug, suppressed the development of experimental allergic encephalomyelitis (EAE) in rats when administered during the incubation period. One dose of mitoxantrone had a favorable effect on EAE even when withheld until after the onset of clinical signs. In a model of relapsing EAE, a single dose during a remission prevented the expected relapse. Mitoxantrone had a particularly favorable effect when administered at the site of inoculation of the encephalitogenic antigen and adjuvant, indicating the importance of its interaction with the regional draining lymph nodes. These results support the possible clinical use of mitoxantrone for immunosuppression.

The role of antigen absorption in the resistance of brown-Norway rats to experimental allergic encephalomyelitis.

The designation of Brown-Norway (BN) rats as resistant to experimental allergic encephalomyelitis (EAE) is an oversimplification. Lewis rats are susceptible and BN rats are usually resistant to EAE after inoculation with guinea pig spinal cord or basic protein in Freund's adjuvant. However, EAE can be produced in BN rats by immunizing with rat cord and carbonyl iron, a particulate adjuvant. In the present work, the possibility that susceptibility of BN rats under these conditions is due only to the special qualities of the adjuvant has been eliminated by producing EAE in them without any adjuvant at all, merely by increasing the absorption and processing of the rat cord antigen. The susceptibility of the F1 hybrids is intermediate with respect to guinea pig cord antigen but it was equal to or greater than either parental strain when tested with rat cord antigen. Histologic evidence that BN rats do not absorb or process neural antigen as well as other strains, and the augmentation of EAE by increasing the dose and absorption of the inoculum, suggest that antigen absorption, processing and presentation is a "bottleneck" for development of EAE in BN rats. Absorption and processing of antigen should be considered along with cellular response, inflammatory mediators and epitope dominance when analyzing susceptibility and resistance to EAE.